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What we will cover today 1.Acute Pain on the wards- Some “go-to” moves. 2.Special circumstances- Problems after Spinal and Epidural anaesthesia If we have time… 1.My patient needs surgery- What does the anesthetist want to know?

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Case Study cont… O/E: pupils 2mm R=L, drowsy. –You increase Oxygen to 100% NRBM –Sats now 94% What is the problem? How long does morphine “last” You decide on Naloxone –What about the pain? –How much? –How often?

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Morphine and Naloxone Morphine –IV Peak 10-20min Duration 1-2hrs –IM Peak 30min Duration 2-3hrs Naloxone –IV Dose 100mcg at a time wait 1min- repeat. –(slow and steady, you can always give more!!) –Duration 30-60min HENCE need to remain monitored and may need repeat dosing (it wears off before morphine!) –What are you aiming for? –Here is an ampoule- draw it up as you would use it! Much longer than most think! Endone peak 30min duration 1-2 hrs

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Fixed After two doses of 100mcg the patient is less drowsy, RR 14, sat 98% You keep her on Oxygen with 15min Obs for the next hour, 30min the hour after that. Pain is settling and she gets a good nights sleep! She thinks you are a hero!

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Take home message All doctors need to have a plan for the patient with severe pain! All patients on IV/IM opiates need Oxygen! Get to know your core drugs- discuss a plan with a senior and try it in daylight hours! –(alone at night is not the time!) Know how to get: 1.Help when you are unsure 2.Yourself and the patient out of trouble! –Have a few “go to moves”

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Case study: “No sympathy” You bolus 500mL and with hold his perindopril 15min later: –BP75/40, HR 52, nauseated –What do you do? What is going on? –Why is this man not maintaining his BP?

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Sensor Response Memory scratcher

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Case study: “Overly sympathetic” You check his sensation: “He is numb to the nipples” “High Block”: –This is a medical emergency –Stop any intrathecal medications –Call a MET –Give IVF, elevate legs, ACLS Treatment: Hopefully the cavalry will arrive! IVF- Starling may help a bit! Vasopressor + chronotropy: Alpha and beta agonist! –Don’t do this unless you know what you are doing!! –Get advise from someone who knows! –This is a registrar “go to move”

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Case Study: “Morphology” As it turns our morphine and Fentanyl in commonly used in spinal anaesthetics. –Here are some charts: these are the areas to look at on the anaesthetic chart for this info. Was it the Morphine or the Fentanyl? Why the delay?? Any ideas?

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Take home message Neuro-Axial blockade can cause major disruption in cardiovascular/Resp function- it can be delayed and present on the ward. –It must be recognised!! Management of Post Op patients needs an understanding of basic physiological principles that many of us forget after med school! Read the Anaesthetic sheet! Its full of goodies! If in doubt ask!! We don’t bite!!

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Quick: other pearls for the ward.. Beta Blockers: It is quiet rare that you need to withhold these (bradycardia, heart block) – generally don’t do it, even if NBM!! Oxycontin: Do not withhold chronic opiates pre- operatively even if NBM! Special patients: The classic “possible opiate seeker”, give the patient the benefit of the doubt initially- seek higher level input thereafter. Tramadol can be handy here- less “buz” but good analgesic. Palliative care: seek higher advise early!! They are lovely people to deal with! Any questions???

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My MET call mantra- “ABC and…” Have a basic plan for the nurses: Identify the nurse looking after the patient, “Jane”: This: –Gives the impression that you are not panicking, –gives others confidence in you and themselves, –and gets things done “Jane, can you please: 1.Increase the oxygen to 100%” “Jane, can you please get someone else to: 1.Check a BSL 2.Do an ECG 3.Get me the notes So that you can tell me about what has happened”. “Thankyou Jane-”

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Thanks “Have fun at work: –do Anaesthetics and/or Intensive Care”

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My patient needs Surgery…

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What does the anaesthetic team need to know? (A part from the basic PMHx and current problem) We want to know what degree of stress/trauma a person can withstand? –The surgeons are about to unleash their fury on them. Key Question: What is their physiological reserve?

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Airway & Anaesthetic History: Airway: –Can their mouth open? –Can their neck move? –Can you see their oropharynx? MP score –Are they obese? Have they had previous anaesthetics? –Were there any problems?